Newly Diagnosed Heart Failure in Patient Safety, Preventive & Ethics — 45yo Man | Ethics | SMLE Q#1620
SMLE Question #1620
Patient Safety, Preventive & Ethics
Ethics
Last updated: February 2026
A 45-year-old man is admitted with newly diagnosed heart failure after returning from travel. He has been taking an oral medication obtained abroad, but his regular medicines are not documented on admission. Digoxin is prescribed electronically, dispensed by the pharmacy, and administered as ordered. Shortly afterward, he develops marked bradycardia and hypotension, and an interaction with an unrecorded home medication is suspected. The admission record does not show that a complete medication history or medication reconciliation was performed. Who is primarily at fault for this adverse event?
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